Authorization to Obtain Healthcare Information--New Patient

Authorization to Obtain Healthcare Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Format: (000) 000-0000.
Patient Address

Street Address

Street Address Line 2

CityState

Zip Code
I authorize the following doctors/hospitals...
1.) Name
Area of Medicine
If hospital, leave blank
Phone Number
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
Address
2.) Name
Area of Medicine
If hospital, leave blank
Phone Number
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
Address
3.) Name
Area of Medicine
If hospital, leave blank
Phone Number
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
Address
4.) Name
Area of Medicine
If hospital, leave blank
Phone Number
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
Address
5.) Name
Area of Medicine
If hospital, leave blank
Phone Number
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
Address
6.) Name
Area of Medicine
If hospital, leave blank
Phone Number
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
Address
...to release
- the last 2 years of office notes
- the last 5 years of labs
- the most recent colonoscopy and path report
- the most recent mammogram
- the most recent Pap smear
- the most recent DEXA scan
- the most recent ECG tracing
- any other imaging or path reports
- a list of all vaccines
- anything else specified in the cover page
to

North Bethesda Primary Care

Fax: 301-941-4404, Phone: 301-941-4414

11300 Rockville Pike, Suite #1015

North Bethesda, MD 20852
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorized Representative (if not the patient)

First NameLast Name
Relationship of Authorized Representative
Phone Number
Format: (000) 000-0000.
Should be Empty:

Authorization to Obtain Healthcare Information

I authorize the following doctors/hospitals...

...to release

to